HLS has frequently worked with our clients to resolve ongoing issues with particular payers that affect a large volume of claims. We have pursued external review, arbitration, litigation, and settlements when warranted.
We have found that certain payers are apt to over-deny claims and uphold their denials even after our appeals have clearly demonstrated that the services should be paid. With those difficult payers, a case-by-case approach is likely to fail without address the broader pattern of payer behavior that contribute to excessive denials. We often submit cases to Independent Review Organizations or Offices of Administrative Hearings after exhausting internal appeals when we feel that the payer’s adjudication was unjust. We have also grouped together related cases to bring up with provider relations representatives, resulting in changes in payer behavior or settlement agreements.
We have also worked with our clients to facilitate payer transitions. In one instance, a major regional payer was purchased by a new vendor, which initially refused to honor the debt obligations of the previous vendor. We eventually reached a settlement agreement to pay all outstanding claims for participating hospitals. In other instances, we have educated new MCOs on proper protocols to ensure that they provide a fair appeals process on behalf of our clients.
Interested in learning more about how HLS can ensure that your major payers treat you fairly? You can contact us and we’ll be happy to provide you with more information.